Best Therapies for Post-concussion Syndrome in Children and Adolescents
Researchers at UC San Francisco have done an extensive review of cases involving children and adolescents with post-concussion syndrome (PCS). They have established what treatments are most applicable for different symptoms. They found that the best way to organize treatment was a breakdown of therapies by four symptom groups: vestibular-ocular, autonomic (or physical), emotional, and cognitive. The study, by Mitul Kapadia et al.,was published in Current Reviews of Musculoskeletal Medicine.
Vestibular-ocular symptoms include dizziness, poor balance, nausea, vision changes and are present in 29% of sports-related concussion, and 63% of patients with persistent concussion symptoms.
Vestibular-ocular symptoms often are the most difficult to treat, but new treatments are being developed for these issues. To determine the best treatment, the researchers recommend screening for the specific type of dysfunction and any cervical injury. Based on this screening, a physician or physical therapist can recommend individualized treatments with vestibular rehabilitation therapy (VRT). Using this treatment, patients have shown robust results in recovering from vestibular-ocular dysfunction. Check out our pages on Vestibular Therapy, Vision Therapy, and Physical Therapy, for more information.
The authors address post-traumatic headache (PTH) at length because “headaches are a predominant symptom” in children with post-concussion syndrome. They point to recent research that shows that cognitive behavioral therapy (CBT) is effective for post-concussion headaches in children. CBT may also enhance or replace medications, with the advantage of eliminating side effects from taking medications.
Additionally, the authors mention that “there was insufficient evidence to recommend any specific pharmacological intervention for PTH.” However, they found one study that showed amitriptyline to be effective, and several studies showed local anesthetic nerve blocks of the scalp to be effective. Recent research points to melatonin as a treatment for PTH and a preventative for migraine headaches. There is some evidence that Vitamin B12, high-dose magnesium, and coenzyme Q-10 may prevent migraine headaches due to concussion. See our pages Medication and Nutrition.
Although not mentioned in this by Mitul Kapadia et al., Concussion Alliance would like to point out that there is some (limited) evidence for craniosacral therapy for persistent concussion symptoms, and members of our community have found it to be both a helpful and easily accessible treatment. See our page, Craniosacral Therapy.
Cognitive behavioral therapy (CBT) is a type of psychological therapy based on changing thought patterns. This therapy helps patients improve their situation, or at least cope with it better. The use of CBT in pediatric cases has been shown to “reduce pain frequency and severity, reduce associated stress, anxiety and depression, improve sleep, and improve functioning across domains, including school and physical activity.”
Studies are showing that CBT shortens the recovery time for PCS, and it also reduces the percentage of concussion patients who develop PCS in the first place. These were not pediatric studies, however.
The goal is that by avoiding negative thoughts, stress, and anxiety in the first place, recovery will not be impacted by any negative emotional or behavioral processes. CBT treatment is likely not only to help emotional symptoms (irritability, anxiety, sadness) but also autonomic (headache, sleep difficulties, light/sound sensitivity) due to their interconnected natures.
The authors suggest that “evaluation by a neuropsychologist with expertise in concussions may help hasten the recovery process.” They found limited evidence for the use of the medications methylphenidate and amantadine for cognitive symptoms. Methylphenidate helps with attention, fatigue, and depression; and amantadine helps stimulates the production of dopamine, for a stimulating effect.
Return to Learn
One of the most challenging parts of pediatric concussions is the return to learn (RTL). Research has shown that “long absences from school have a deleterious effect on children’s psychological and academic functioning” while gradual RTL is shown to help children remain engaged with peers and fall behind in school less.
Kapadia’s research team stresses that there are two major considerations in a RTL: effective communication and adjustments. Effective communication between parents, schools, and medical professionals allows everyone involved in the child’s health and education to aid their recovery and manage their workload effectively.
Adjustments include making sure first that the child is ready to return to school (they can read for 30 minutes without straining) then starting their return to school with half days and limited or no homework or examinations. Their slow integration is crucial to a full recovery and continuing psychological health as well.
Any return to sport should be delayed until after a full return to learn process has been completed as the risk of repeat concussions is large, and the symptoms are often worse after an additional concussion.
As new therapies come out and more research is done the need for continuing education on concussions is a top priority, particularly in pediatric concussions where the effects can be felt for a lifetime.